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Guideline Summary
Guideline Title
American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis.
Bibliographic Source(s)
Grossman JM, Gordon R, Ranganath VK, Deal C, Caplan L, Chen W, Curtis JR, Furst DE, McMahon M, Patkar NM, Volkmann E, Saag KG. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken). 2010 Nov;62(11):1515-26. [104 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis. Arthritis Rheum 2001 Jul;44(7):1496-503.

Scope

Disease/Condition(s)

Glucocorticoid-induced osteoporosis

Guideline Category
Counseling
Prevention
Risk Assessment
Treatment
Clinical Specialty
Endocrinology
Family Practice
Geriatrics
Internal Medicine
Orthopedic Surgery
Rheumatology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Physician Assistants
Physicians
Guideline Objective(s)

To educate and update physicians on the prevention and treatment of glucocorticoid-induced osteoporosis

Target Population

Adults who are or will be receiving glucocorticoids

Interventions and Practices Considered
  1. Counseling for lifestyle modification including smoking cessation, avoiding excessive alcohol, nutrition (calcium and vitamin D intake), and weight bearing activities
  2. Fall risk assessment
  3. Serum 25-hydroxyvitamin D measurement
  4. Measurement of baseline and annual height
  5. Assessment of prevalent and incident fragility fracture
  6. Radiographic imaging of spine or vertebral fracture assessment
  7. Calcium and vitamin D supplementation
  8. Bone mineral density measurement (dual x-ray absorptiometry) (baseline and serial)
  9. Bisphosphonates (alendronate, risedronate, zoledronic acid)
  10. Teriparatide
  11. Assessment of osteoporotic medication compliance

Note: Other pharmaceutical therapies, including raloxifene, hormone replacement therapy, and ibandronate, were considered but not recommended.

Major Outcomes Considered
  • Bone mineral density changes
  • Rates of vertebral fracture reduction
  • Rates of non-vertebral or major osteoporotic fracture reduction

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Systematic Literature Review

The guideline authors conducted a systematic review of the therapies currently approved for the treatment of postmenopausal osteoporosis or glucocorticoid-induced osteoporosis (GIOP) in the United States, Canada, or the European Union as well as calcium, vitamin D, and testosterone. Articles were limited to randomized clinical trials (RCTs) or controlled clinical trials (CCTs) of human subjects reported in English with an available abstract. The study duration must have been ≥6 months and all subjects were required to have incident or prevalent glucocorticoid use. With the assistance of a professional research librarian, the authors replicated the search strategy employed in the Comparative Effectiveness of Treatments for Low Bone Density (including Osteoporosis) Report prepared for the Agency for Healthcare Research and Quality for alendronate, risedronate, ibandronate, zoledronic acid, calcitonin, teriparatide, and strontium. They searched Medline (through PubMed) by applying MeSH headings and relevant keywords with references from January 1966 through August 28, 2008 using Cochrane's Highly Selective Search Strategy to improve the specificity of the search. Searches for calcium, vitamin D, estrogen, and testosterone were performed in a similar manner, but limited to GIOP. Using the Cochrane Handbook's guidance, they also conducted similar searches of EMBASE in CENTRAL. Details of the search strategy are listed in Supplementary Appendix A (available in the online version of this article http://onlinelibrary.wiley.com/doi/10.1002/acr.20295/suppinfo External Web Site Policy). Additionally, abstracts from the 2007–2008 American College of Rheumatology (ACR) Annual Scientific Meeting, European League Against Rheumatism annual European Congress of Rheumatology, Annual Meeting of the American Society for Bone and Mineral Research, and European Calcific Tissue Society European Symposium on Calcified Tissues were manually searched for relevant RCTs. The Core Executive Panel and Expert Advisory Panel members contributed expert-identified studies to complete the search.

Three reviewers screened each title and abstract for relevance to the specific aims of the predefined inclusion criteria for the evidence report. This process resulted in a total of 53 articles meeting inclusion criteria and these publications formed the basis of the evidence report.

Number of Source Documents

53 articles met inclusion criteria and these publications formed the basis of the evidence report.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

A Data were derived from multiple randomized controlled trials (RCTs) or a meta-analysis.

B Data were derived from a single randomized controlled trial or nonrandomized study.

C Data were derived from consensus, expert opinion, or case series.

Note: Although few RCTs were performed exclusively in premenopausal patients, many studies did include premenopausal women as part of the overall cohort. These studies were therefore included when determining the evidence grade for recommendations for premenopausal women and men younger than age 50 years.

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review with Evidence Tables
Description of the Methods Used to Analyze the Evidence

Accepted articles were reviewed independently by 2 of the 7 reviewers, and the consensus on the relevant data was entered into a standardized data abstraction form. For each randomized controlled trial (RCT) and controlled clinical trial (CCT), study characteristics, sample size, outcomes, and quality assessment (calculated using the 5-point Jadad score) were reported in tabular form. Jadad scores are based on a 5-point scale, with higher scores suggesting higher-quality studies. The mean Jadad score for the 53 included articles was 2.44 (interquartile range 1–3). This score indicated that the articles as a whole were of only moderate quality. The principal investigator adjudicated discrepant results. Relevant meta-analyses were also described in the report.

The function of the evidence report was to provide the data for evaluation of clinical scenarios used to illustrate the key permutations of potential clinical interventions for the evaluation and management of glucocorticoid-induced osteoporosis. Some clinical scenarios, such as those involving repeat bone mineral density (BMD) testing, did not have RCT data as supportive evidence. In those situations, qualitative literature reviews and expert-identified articles were used to summarize existing evidence. This summarized data helped to guide the development of the clinical scenarios and formed the basis for the evidence report that was used in the next phase of the recommendations development.

Methods Used to Formulate the Recommendations
Expert Consensus (Delphi)
Expert Consensus (Nominal Group Technique)
Description of Methods Used to Formulate the Recommendations

Topic Development

To update the recommendations, the guideline authors incorporated the existing concepts from the 2001 guidelines and also refined the scope of the project. The guideline authors convened an Expert Advisory Panel comprised of 6 rheumatologists with expertise in glucocorticoid-induced osteoporosis (GIOP), including guideline development. To narrow the scope of the work and because of limited available data in certain areas, the Expert Advisory Panel set the following restrictions for the recommendations: first, the inclusion of medications approved for use in the treatment of osteoporosis in the United States, Canada, or the European Union; second, the exclusion of GIOP in the transplant populations; third, the exclusion of GIOP in the pediatric population; and fourth, the exclusion of inhaled glucocorticoids.

The guideline authors next constructed the clinical scenarios that would be used by the Task Force Panel to develop the recommendations. An example of a clinical scenario was "In a high risk patient starting glucocorticoids with an anticipated duration of >3 months or on long-term therapy, which of the following medications would be appropriate to use based on a range of glucocorticoid doses?" followed by the list of all potential medications to treat or prevent GIOP. The complete set of scenarios is available in the Supplementary Appendix (available in the online version of this article at http://onlinelibrary.wiley.com/doi/10.1002/acr.20295/suppinfo External Web Site Policy).

In an effort to make the process of evaluating the clinical scenarios both feasible and clinically meaningful, the guideline authors collapsed multiple risk factors for fractures into 3 fracture risk categories: high, medium, and low risk, guided in part by the FRAX risk assessment tool. The FRAX tool uses updated, evidence-based estimates of absolute fracture risk and was created for the purpose of quantitatively integrating numerous clinical factors into a clinically useful risk prediction model. Using the FRAX calculator, the Expert Advisory Panel defined a 10-year risk of a major osteoporotic fracture of 10% or less as low risk, 10–20% as medium risk, and greater than 20% or a T score of less than or equal to -2.5 or a history of a fragility fracture as high risk (which is the threshold for cost-effective treatment recommended by the National Osteoporosis Foundation). See Figure 2 in the original guideline document for typical examples of postmenopausal women and men age ≥50 years with a history of glucocorticoid use at high, medium, and low risk of fracture in the absence of other risk factors.

Research and Development/University of California, Los Angeles (RAND/UCLA) Appropriateness Method Used by the Task Force Panel

The RAND/UCLA Appropriateness Method, which incorporates elements of the nominal and Delphi method, was used to generate the recommendations presented in this report. The RAND/UCLA Appropriateness Method was developed to combine the best available scientific evidence with the collective judgment of experts to yield a statement regarding the appropriateness of a treatment based on patient-specific symptoms, medical history, and test results. The method combines a systematic review of the scientific literature with expert opinion and yields specific criteria of appropriateness that can be used as the basis for review criteria, practice guidelines, or both. This technique has previously been described as the best systematic method of combining expert opinion and evidence.

As the first step in this process, the Task Force Panel, which consisted of 10 individuals from the fields of rheumatology, endocrinology, and geriatrics, and a patient care advocate, received the evidence report and case scenarios. The Task Force Panel independently rated the appropriateness of the specific interventions within the context of the clinical scenarios with varying fracture risk, glucocorticoid dose, and duration. Instructions for grading scenarios and definitions of all variables were provided by e-mail and discussed during a conference call. The Task Force Panel was asked to use the evidence as summarized in the evidence report as well as their own clinical judgment to rate the appropriateness of employing a particular therapy in the context of each clinical scenarios using a 9-point Likert scale, where 1 = appropriate and 9 = not appropriate. Results from the first round of voting were tabulated and presented at a face-to-face panel meeting comprised of the Core Expert Panel and Task Force Panel. The summarized anonymous scores, including range and median as well as the panelist's own ranking, were provided to each voting member. Areas of discrepancy as well as areas of agreement were discussed and a second round of anonymous voting by the Task Force Panel alone occurred using the same scale. Vitamin D and calcium were evaluated as additive therapy and testosterone and estrogen as primary therapy in hypogonadal patients. The results of the second round of voting determined the updated recommendations. The clinical scenarios specifically did not attempt to prioritize the use of one drug over another when both were deemed appropriate in a particular circumstance.

At the face-to-face meeting, additional questions related to risk factors for premenopausal patients arose that were not adequately addressed by the systematic review. Therefore, voting for premenopausal women and for men age <50 years without prior fragility fracture was deferred until an additional literature search to identify non-randomized controlled trial/controlled clinical trial (RCT/CCT) studies had been performed and disseminated to panel members and discussed in a subsequent conference call.

Statistical Analysis

Recommendations applying to individual scenarios were endorsed when the median score from the panelist voting fell in the 1 to 3 range and there was no disagreement. Disagreement was defined as 3 or more of the 10 voting panelists rating the scenario in the middle or highest tertiles (i.e., 4 to 9). Only positive statements were included in the recommendations. Absence of any recommendation should not be construed to suggest that a treatment was inappropriate in particular settings; the absence of a recommendation generally implied only inadequate or conflicting evidence.

The authors used the Appraisal of Guidelines Research and Evaluation (AGREE) instrument to help assure that the updated recommendations covered all the important domains and attributes. The AGREE instrument grades elements of validity and includes 6 sections: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, applicability, and editorial independence.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation

In addition to traditional manuscript review, a draft of the evidence report was submitted to the American College of Rheumatology (ACR) Guidelines Subcommittee, ACR Quality of Care Committee, and ACR Board of Directors for comments and recommendations, which were incorporated into the final recommendations.

Recommendations

Major Recommendations

The levels of evidence supporting the recommendations (A-C) are defined at the end of the "Major Recommendations" field.

Recommendations for Assessment, Counseling for Lifestyle Modifications, and Followup of All Patients Receiving Glucocorticoid Therapy

The 17 recommendations concerning counseling for lifestyle modifications and followup of patients receiving glucocorticoids are shown in the tables below. In addition to the recommendations listed, using the smallest dose of glucocorticoid for the shortest duration possible was recommended as an important strategy to minimize osteoporosis risk. Since there may be no dose of glucocorticoids that does not accelerate bone loss or increase fracture risk, recommendations for counseling and assessment are extended to all doses of glucocorticoids used or expected to be used for at least 3 months.

Table: Recommendations on Counseling for Lifestyle Modification and Assessment of Patients Starting Glucocorticoids at Any Dose with an Anticipated Duration ≥3 Months

Recommendation Level of Evidence
Weight-bearing activities C
Smoking cessation C
Avoidance of excessive alcohol intake (>2 drinks per day) C
Nutritional counseling on calcium and vitamin D intake C
Fall risk assessment C
Baseline dual x-ray absorptiometry C
Serum 25-hydroxyvitamin D level C
Baseline height C
Assessment of prevalent fragility fractures C
Consider radiographic imaging of the spine or vertebral fracture assessment for those initiating or currently receiving prednisone ≥5 mg/day or its equivalent C
Calcium intake (supplement plus oral intake) 1,200–1,500 mg/day* A
Vitamin D supplementation* A
*Recommendations for calcium and vitamin D supplementation are for any dose or duration of glucocorticoids, rather than a duration of >3 months.

Table: Recommended Monitoring for Patients Receiving Prevalent Glucocorticoid Therapy for a Duration of ≥3 Months

Recommendation Level of Evidence
Consider serial bone mineral density testing C
Consider annual serum 25-hydroxyvitamin D measurement C
Annual height measurement C
Assessment of incident fragility fracture C
Assessment of osteoporosis medication compliance C

The panel recommended that an assessment of fall risk could include asking patients about previous falls and observing their gait. A variety of other approaches to fall risk evaluation are also available. The panel recommended that clinicians consider vertebral fracture assessment (VFA), especially in the setting of significant height loss or a history of back pain consistent with a fracture, or conventional spine imaging because vertebral fractures are often asymptomatic, and might change treatment recommendations for patients receiving steroids who would otherwise be considered a low or medium risk. While grade 2 and 3 vertebral fractures classified according to the Genant semiquantitative method have been shown to have high specificity for vertebral fracture, the panel noted that more research is needed to improve the specificity of grade 1 fractures noted on vertebral fracture assessment.

Calcium and vitamin D supplementation counseling was recommended for all patients beginning glucocorticoid therapy. Vitamin D supplementation to achieve "therapeutic" levels of 25-hydroxyvitamin D, or dosages of 800–1,000 IU/day are 2 target dosing regimens; however, glucocorticoids can interfere with vitamin D absorption and may necessitate a higher supplementation dose to achieve therapeutic levels. Although serial bone density testing was recommended, the interval of such testing remains controversial. Factors that will influence the frequency of testing include the presence of additional risk factors for fracture, whether or not osteoporosis therapy has already been initiated, the results of the previous bone mineral density (BMD), the dose of steroids, and the rate of change of the BMD.

Recommendations for Low- and Medium-Risk Postmenopausal Glucocorticoid-Treated Women and Glucocorticoid-Treated Men Age ≥50 Years

The recommendations for low- and medium-risk patients, as shown in the table below, were to start prescription osteoporosis therapy for patients with an anticipated glucocorticoid usage duration of ≥3 months or those on prevalent glucocorticoid therapy for at least 3 months. The glucocorticoid dose warranting therapeutic intervention represents the practitioner's intended average daily dose and varies according to the specific medication being considered.

Table: Pharmacologic Recommendations for Postmenopausal Women and Men Age ≥50 Years Starting Glucocorticoid Therapy with an Anticipated Duration of ≥3 Months, or Prevalent Glucocorticoid Therapy of a Duration of at Least 3 Months (unless otherwise noted)

Recommendation Level of Evidence
Low-risk patient

Alendronate for ≥7.5 mg/day prednisone
OR

A

Risedronate for ≥7.5 mg/day prednisone
OR

A

Zoledronic acid for ≥7.5 mg/day prednisone*

B

Medium-risk patient

Alendronate for any dose of glucocorticoids
OR

A

Risedronate for any dose of glucocorticoids
OR

A

Zoledronic acid for ≥7.5 mg/day prednisone*

B

High-risk patient†

Alendronate
OR

A

Risedronate
OR

A

Zoledronic acid*
OR

B

Teriparatide‡

B

*Head-to-head comparison data available in the Discussion section in the original guideline document.
†Any anticipated dose or duration of glucocorticoids justifies initiating prescription therapy for high-risk patients.
‡For ≥5 mg/day prednisone with a duration ≤1 month and for any dose of glucocorticoids with a duration >1 month. Head-to-head comparison data available in the Discussion section in the original guideline document.

Recommendations for High-Risk Postmenopausal Glucocorticoid-Treated Women and Glucocorticoid-Treated Men Age ≥50 Years

Consistent with the National Osteoporosis Foundation Guidelines that suggest treatment when the 10-year risk of major osteoporotic fractures is ≥20% (the high-risk group), the Task Force Panel recommended that these patients receive prescription osteoporosis therapy even in the absence of glucocorticoid use, hence the recommendations for a duration of glucocorticoids of <1 month (see table above).

Recommendations for Premenopausal Women and Men Age <50 Years

Men younger than age 50 years were considered together with the premenopausal women. These 2 populations were thought to represent a similar patient group, insofar as there is limited evidence for the treatment of glucocorticoid-induced osteoporosis (GIOP) in both these populations. Furthermore, the risk factors that influence fracture propensity in these populations have not been well defined. The Fracture Risk Assessment Tool (FRAX) tool is currently not applicable to premenopausal women or men younger than age 40 years. Additionally, the long-term safety of medications used to treat GIOP in this population, and the risk of these medications to a fetus, either from current or previous exposure, is not well defined. For these reasons, the panel concluded that they could make recommendations only for those with a prevalent fragility fracture who were clearly at higher risk for additional fracture. For women of childbearing potential, drugs with shorter half-lives were recommended (as shown in the table below). For those of nonchildbearing potential, the recommendations were similar to those for postmenopausal women and for men except that the anticipated duration of glucocorticoids required to trigger therapy was 3 months. The panel suggested this area warranted further research.

Table: Recommendations for Premenopausal Women and Men Under Age 50 Years with a History of Fragility Fracture

  Grade of Recommendation
1–3 MONTHS OF GLUCOCORTICOIDS
Nonchildbearing potential

Alendronate if receiving prednisone ≥5 mg/day
OR

A

Risedronate if receiving prednisone ≥5 mg/day
OR

A

Zoledronic acid if receiving prednisone ≥7.5 mg/day*

B

Childbearing potential—Inadequate data for recommendation
≥3 MONTHS OF GLUCOCORTICOIDS
Nonchildbearing potential

Alendronate for any dose
OR

A

Risedronate for any dose
OR

A

Zoledronic acid for any dose*
OR

B

Teriparatide for any dose*

B

Childbearing potential

Alendronate if prednisone ≥7.5 mg/day
OR

A

Risedronate if prednisone ≥7.5 mg/day
OR

C

Teriparatide if prednisone ≥7.5 mg/day*

C

*Head-to-head comparison data available in the Discussion section of the original guideline document.

Definitions:

Levels of Evidence

A Data were derived from multiple randomized controlled trials (RCTs) or a meta-analysis.

B Data were derived from a single randomized controlled trial or nonrandomized study.

C Data were derived from consensus, expert opinion, or case series.

Note: Although few RCTs were performed exclusively in premenopausal patients, many studies did include premenopausal women as part of the overall cohort. These studies were therefore included when determining the evidence grade for recommendations for premenopausal women and men younger than age 50 years.

Clinical Algorithm(s)

Clinical algorithms are provided in the original guideline document for the following:

  • Approach to postmenopausal women and men age >50 years initiating or receiving glucocorticoid therapy
  • Approach to premenopausal women and men age <50 years initiating or receiving glucocorticoid therapy

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for select recommendations (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Improved awareness and increased rate of counseling for and treatment of glucocorticoid-induced osteoporosis

Potential Harms

All medications have their own risk profiles (reviewed in the evidence report available in the Supplementary Appendix, which is available in the online version of this article at http://onlinelibrary.wiley.com/doi/10.1002/acr.20295/suppinfo External Web Site Policy) that need to be considered when evaluating individuals.

Qualifying Statements

Qualifying Statements
  • Guidelines and recommendations developed and/or endorsed by the American College of Rheumatology (ACR) are intended to provide guidance for particular patterns of practice and not to dictate the care of a particular patient. The ACR considers adherence to these guidelines and recommendations to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient's individual circumstances. Guidelines and recommendations are intended to promote beneficial or desirable outcomes but cannot guarantee any specific outcome. Guidelines and recommendations developed or endorsed by the ACR are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice.
  • The American College of Rheumatology is an independent professional, medical, and scientific society which does not guarantee, warrant, or endorse any commercial product or service.
  • Since even rigorously developed guidelines have limitations in informing individual patient care, the authors selected the term "recommendations" to describe this work. These recommendations should not supplant clinical judgment, nor are they intended to serve as indicators of quality of care. Rather, they provide expert opinion and evidence-based guidance on the prevention and treatment of glucocorticoid-induced osteoporosis (GIOP).

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Clinical Algorithm
Foreign Language Translations
Patient Resources
Quick Reference Guides/Physician Guides
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Grossman JM, Gordon R, Ranganath VK, Deal C, Caplan L, Chen W, Curtis JR, Furst DE, McMahon M, Patkar NM, Volkmann E, Saag KG. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res (Hoboken). 2010 Nov;62(11):1515-26. [104 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1996 Sep 3 (updated 2010 Nov)
Guideline Developer(s)
American College of Rheumatology - Medical Specialty Society
Source(s) of Funding

American College of Rheumatology (ACR)

Guideline Committee

Core Executive Panel/Task Force Panel

Composition of Group That Authored the Guideline

Authors: Jennifer M. Grossman; Rebecca Gordon; Veena K. Ranganath; Chad Deal; Liron Caplan; Weiling Chen; Jeffrey R. Curtis; Daniel E. Furst; Maureen McMahon; Nivedita M. Patkar; Elizabeth Volkmann; and Kenneth G. Saag

Financial Disclosures/Conflicts of Interest

Dr. Deal has received consultant fees, speaking fees, and/or honoraria (more than $10,000 each) from Lilly, Amgen, and Genentech. Dr. Curtis has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Eli Lilly and Procter & Gamble, and (more than $10,000 each) from Novartis, Amgen, Roche/Genentech, and Merck. Dr. Saag has received consultant fees, speaking fees, and/or honoraria (less than $10,000 each) from Merck, Lilly, Novartis, Aventis, Genentech, AstraZeneca, Pfizer, and Horizon.

Guideline Endorser(s)
American Society for Bone and Mineral Research - Professional Association
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis: 2001 update. American College of Rheumatology Ad Hoc Committee on Glucocorticoid-Induced Osteoporosis. Arthritis Rheum 2001 Jul;44(7):1496-503.

Guideline Availability

Electronic copies: Available from the Arthritis Care & Research Journal Web site.

Print copies: Available from the American College of Rheumatology, 1800 Century Place, Suite 250, Atlanta, GA 30345.

Availability of Companion Documents

The following are available:

  • American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Appendices. 162 p. Available in Portable Document Format (PDF) from the Arthritis Care & Research Journal Web site.
  • American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Clinician's guide. 7 p. Available in PDF from the Arthritis Care & Research Journal Web site.
Patient Resources

The following is available:

  • Glucocorticoid-induced osteoporosis. 4 p. Available in Portable Document Format (PDF) in English External Web Site Policy and Spanish External Web Site Policy from the American College of Rheumatology (ACR) Web site.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This summary was completed by ECRI on October 17, 2001. The information was verified by the guideline developer as of May 8, 2002. This summary was updated by ECRI Institute on June 29, 2011. The updated information was verified by the guideline developer on July 25, 2011. This summary was updated by ECRI Institute on October 12, 2011 following the U.S. Food and Drug Administration (FDA) advisory on Reclast (zoledronic acid).

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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